What treatments are covered by Swiss health insurance?


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Medication: what does health insurance cover?

Basic health insurance (LAMal) covers medication prescribed by a doctor and used according to the instructions provided.
The drug must also appear on the list of specialties (LS). Note that reimbursement of a drug on the list of specialties may be limited to certain indications or to a given quantity, indicated in the list of specialties.

Can reimbursement be obtained for a drug prescribed by a doctor but not included in the list of specialties?

By default, basic health insurance does not cover the cost of drugs not included in the list of specialties. Nevertheless, it may exceptionally be reimbursed if it meets the same conditions as a drug used outside the prescribed limitations.
Please note that doctors must inform you if they prescribe a drug that is not on a list.
If a drug is not covered by basic insurance, taking out supplementary insurance tailored to these reimbursements may be a suitable solution.

Benefits and treatments abroad covered by basic insurance

In principle, basic insurance only reimburses compulsory services provided in Switzerland by recognized healthcare personnel.
However, there are exceptions for temporary stays abroad. These exceptions are divided into two types of country:
  • In an EU/EFTA country: On presentation of your European health insurance card (issued by your health insurance fund), you will be entitled to reimbursement of all medically necessary services. The level of reimbursement will be the same as for people insured in the country.
  • Outside the EU/EFTA: Basic health insurance reimburses the costs of emergency medical treatment in cases where a return to Switzerland is not possible for medical reasons. These treatments are reimbursed at a maximum of twice the amount that would have been paid by the insurer if the treatment had been carried out on Swiss territory.
It is possible to obtain medical treatment abroad if it cannot be provided on Swiss territory. In this case, your doctor must draw up a request to your health insurance company's medical adviser, who will decide whether or not to cover the costs.

Medication abroad covered by health insurance

Basic insurance only reimburses medication needed to treat an illness during a temporary stay abroad.

Vaccines and prevention covered by health insurance

Compulsory health insurance reimburses the costs of several vaccines based on the guidelines and recommendations of the Swiss vaccination plan. Vaccine reimbursements include:
  • Tetanus, whooping cough, poliomyelitis, diphtheria, haemophilus influenza type b, chickenpox and measles, mumps and rubella
  • Hepatitis B and A (for certain risk groups)
  • Influenza for people over 65 and people at risk
  • Vernoestival meningoencephalitis
  • Cervical cancer for girls aged 11 to 26
  • Vaccine against covid-19 carried out in the context of a pandemic
Vaccines to prevent travel abroad are not covered.

Does health insurance cover maternity costs?

What check-ups are covered during and after pregnancy?

Basic health insurance covers seven check-ups during a normal pregnancy. In the case of a high-risk pregnancy, these examinations may be repeated as often as necessary. Note that in the case of a high-risk pregnancy, an examination via cardiotocography is also covered.
Following childbirth, and between the 6th and 10th week after delivery, a comprehensive check-up including an intermediate history, gynecological and clinical status including counseling is covered by basic insurance.
In the event of miscarriage or medically indicated termination of pregnancy between the 13th and 23rd completed weeks of pregnancy, a comprehensive check-up is also covered, including gynecological and clinical status, counseling, intermediate anamnesis, laboratory tests and ultrasound according to the individual's clinical assessment.

How many ultrasounds are covered per pregnancy?

In the case of a normal pregnancy, basic insurance covers an ultrasound between weeks 12 and 14, as well as an ultrasound between weeks 20 and 23.
In the case of a high-risk pregnancy, additional ultrasounds are covered if deemed necessary by the gynecologist based on the individual's clinical assessment.

Does basic insurance cover childbirth preparation courses?

Basic insurance reimburses up to 150 francs in the following cases:
  • Individual or group childbirth preparation classes given by a midwife or midwifery organization
  • Birth counseling interview with a midwife or midwifery organization
  • Planning and organization of the postnatal period at home and breastfeeding preparation

Does health insurance cover first-trimester testing?

Indeed, basic health insurance covers the prenatal analysis test for the risk of trisomy 21, 18 and 13 by measuring nuchal translucency by ultrasound between the 12th and 14th week.

Is the trisomy diagnostic test (DPNI test) covered by health insurance?

Basic health insurance covers the DPNI test for the purpose of detecting trisomy 21, 18 or 13 from the 12th week of pregnancy.

Hospital or home birth: what does health insurance cover?

Basic health insurance covers covers delivery in hospital, in a birthing center or at home, provided the first two facilities are on the hospital list of the canton of residence.

Does health insurance cover the cost of newborn care?

The mother's basic health insurance covers newborn care and hospitalization. It should be noted that these coverages, considered as maternity benefits not subject to cost sharing.

Inpatient coverage

Basic insurance covers your medical expenses in the event of a hospital stay. Please note that certain conditions apply:
  • You will be placed in a general ward
  • You will have to go to a recognized hospital in your canton
  • You will not have a free choice of specialist or doctor
  • You will have to pay a stay fee of 15 francs per day of hospitalization
Please note that in the case of coverage by supplementary hospital insurance, benefits are often higher and the remainder payable by you much lower.

Coverage of outpatient treatment

Basic insurance covers outpatient treatment by a recognized doctor or specialist.

Medical transport and rescue

It is important to stress the fact that transport or rescue costs can be very expensive in some cases.
Basic health insurance covers 50% of your transport costs up to a maximum of CHF 5,000 per year for medically necessary transport. This ceiling is reduced to 500 francs per year if the insured's life is not in danger.
In the event of an accident requiring transport to the emergency room, your employer's accident insurance will come into play (if you work more than 8 hours a week) and transport costs will be fully covered.

Coverage of aids and appliances

Basic insurance covers doctor-prescribed aids and appliances such as bandages, inhalation devices, incontinence aids or dressings up to a maximum amount.

Bathing cures and health insurance

Basic insurance covers CHF 10 per day for 21 days a year in the case of a cure prescribed by your doctor, taking place in an approved spa establishment.

Dental care

Does health insurance cover dental care?

Basic health insurance does not cover dental care except in the event of illness or accident. Please note that conditions likely to require dental treatment to be paid for by basic health insurance are listed in articles 17 to 19 of the Health Insurance Benefits Ordinance.

Coverage of glasses and contact lenses

Basic insurance covers up to 180 francs a year for children and young people up to the age of 18 for glasses and contact lenses prescribed by an ophthalmologist.
In some cases, basic insurance covers optical costs in the case of certain illnesses.

Home care and EMS: What does health insurance cover?

In the event that, following an operation or illness, care at home or in a medico-social establishment (EMS) is required, basic insurance covers a contribution towards the care prescribed by your doctor.
Please note that reimbursement for care at home or in a medico-social facility is subject to co-payment.
Nevertheless, basic insurance does not cover household help, nor accommodation and maintenance in a medico-social facility.
Alexis Milon
Updated on: 01.02.2024Written by Alexis MilonHead of health insurance department at Comparea.
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